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Gun violence: A public health crisis

Gun violence is a fraught topic in our country, with much of the debate framed by ideology, fear and rigidity. But following a string of tragedies, culminating with the recent shooting deaths of 26 people (including 20 children) in Newtown, Conn., national debate has been transformed. A public health framework — the pragmatic, data-based approach that has tackled challenges ranging from influenza to obesity, from polio to heart attacks, from smoking to traffic safety — offers a fresh point of view, important insights, and evidence-based guidelines for action.

What is the magnitude of the problem? Over 30,000 Americans each year — close to 600 each week — lose their lives to guns. The firearm homicide rate in the U.S. is 20 times higher than in other wealthy nations. In 2011, the last year for which statewide data are available, Washington listed 619 firearm deaths, including 492 suicides, 92 homicides, and 9 classified as “accidental.” (Firearms accounted for 50 percent of all suicides and 51 percent of all homicides.) For comparison, motor vehicle traffic crashes accounted for 497 deaths in the state that year, drowning 123, and poisoning (including drug-related deaths) 1,075. In King County, more than 125 people lose their lives to firearms each year, and hundreds more are injured. The burden — in dollars and in human suffering — is enormous.

The impact of gun violence disproportionately impacts communities already struggling with poverty and poor health. In King County, the firearm homicide rate among blacks is seven times higher than among whites. Homicides by firearms are more likely among residents of south and central Seattle (including Beacon/Georgetown/South Park, Southeast Seattle, Delridge and central Seattle) and South King County.

What do we know about firearm risks? A great deal of research data indicates that a gun in the home increases the risk that someone in that home will die of a firearm injury. Much of this data comes from studies conducted, in part, in Seattle. An early 1980s study found that for each case of self-protection homicide involving a firearm kept in the home, there were 1.3 accidental deaths, 4.6 criminal homicides and 37 suicides involving firearms. Handguns were used in 70.5% of these deaths. Studies comparing Seattle to Vancouver, B.C., which has very different gun control laws, found that despite similar overall rates of criminal activity and assault, the risk of death from homicide was 63 percent higher in Seattle than in Vancouver. Virtually all of this excess risk was explained by a 4.8-fold higher risk of being murdered with a handgun in Seattle as compared with Vancouver. Similarly, people 15 to 24 years old had a 38 percent higher suicide rate in King County than in the Vancouver area and virtually all the difference was due to an almost 10-fold higher rate of suicide by handguns in King County. Homes that contain guns are associated with a 2.7-fold greater risk of homicide and a 4.8-fold increased risk of suicide.

Does mental illness play a role? When random acts of mass violence such as the Newtown shooting occur, the public perception is often that mental illness must have caused the violence. This perception, sometimes perpetuated by news reports, risks increasing the stigma of mental illness and could keep people from seeking needed treatment. In fact, people with mental illness are much more likely to be the victims of violence, and much more likely to die of suicide by firearms, than to kill someone else using a firearm. The focus on mental illness also ignores potentially larger risk factors that contribute to violence, such as substance abuse, poverty, having a history of abuse and victimization, and social isolation. Early identification of mental illness and broader access to services are an important part of any comprehensive plan to reduce the risk of gun violence, but they are not sufficient.

What can we do? Several broad approaches have been put forward to reduce gun violence. Many of these are supported by evidence that they work, and some are especially relevant to Washington state:

Ensure that all firearm purchases are facilitated through a federally licensed gun dealer and require a background check. This is particularly important in Washington state, where there is a large unregulated gun show market. The ease with which an individual can purchase guns in our state while avoiding a background check has resulted in a dubious distinction: Washington is the leading crime-gun supplier to Canada, and, along with border states, has been a leading crime-gun supplier to Mexico. Knowing more about who purchases guns is important for other evidence-based strategies.

Prohibit high-risk individuals from purchasing guns. Individuals at high risk of committing a violent crime include those who have been convicted of a violent misdemeanor, a violent juvenile crime, drug trafficking or stalking; gang members, and those who have violated a restraining order. Federal restrictions of gun purchase for persons with serious mental illness should be focused on the dangerousness of the individual. We can consider establishing a minimum age of 21 years for handgun purchase or possession.

Make the product safer. New advances in gun technology have potential safety benefits and risks. Personalized guns that can only be fired by the owner are being marketed and could play a role for handgun owners and law enforcement officials who wish to reduce the likelihood that their weapon could be used against them. Banning sales of highly lethal assault weapons and high capacity ammunition magazines may be one strategy to reduce the lethality of gun violence. As with other commercial goods, the Federal Consumer Product Safety Commission should monitor the safety of firearms and ammunition.

Protect children from gun violence through adoption of safe storage and child access prevention laws. The past year has been a particularly painful one for gun violence among young people in Washington state. Many children have been killed by weapons that were not safely stored. These are devastating events, typically involving family members. The burden of loss and sorrow is unfathomable for the family, the child who fired the weapon, and grieving parents. Other children have been seriously injured and face years of recovery. Guns are easy to get in Washington. More than 14 percent of 8th grade students and almost 23 percent of 12th grade students here reported it was “sort of” or “very easy” to get a handgun, according to the 2010 Healthy Youth Survey. Most firearms used in suicide attempts and unintentional injuries were stored in the residence of the victim, a relative or friend. The risk includes unintentional shootings, assaults and homicides, suicide, theft and threats in schools and other community settings. Unintentional firearm injuries can largely be prevented by requiring that firearms and ammunition be safely stored and locked in households to which children have access.

Allow the citizens of cities or counties to pass more stringent gun safety laws if they wish. The current law in Washington prohibits cities or counties from passing more restrictive gun safety legislation, and limits the ability of voters to address gun safety in their communities.

It’s not enough to implement effective strategies. We also need to avoid ineffective strategies and those that are not supported by evidence:

Many approaches focusing simply on gun safety education have not been effective. Gun safety education aimed at children was found to have no impact on a child’s interest in picking up, and pretending to fire, a test gun. Gun safety curricula taught through schools have generally not been effective.

Putting guns in the classroom is likely to put children at higher risk. There have been recent calls to suggest that teachers keep a gun in the classroom, or to post armed guards at schools. There is no evidence that this approach would work.

We may be at a tipping point, a point at which people from all walks of life — parents, law enforcement officials, hunters, target shooters, public health and health care professionals, and others — can find common ground. A recent national survey, fielded in the aftermath of the Newtown tragedy, showed remarkable levels of agreement on policies to reduce gun violence. including: requiring universal background checks for all gun sales (supported by 89 percent) and prohibiting gun ownership by high-risk individuals, including those convicted of a serious crime as juveniles (83 percent) and those convicted of violating a domestic-violence restraining order (81 percent). Some of these policies won strong support from NRA members; for instance, 74 percent of NRA members supported universal background checks.

So what’s next? First, we need to reframe the conversation about gun violence. As a public health challenge that extracts a heavy toll on our communities, it requires public health solutions. This approach will be presented and discussed at Town Hall Seattle on Monday evening.

Next, we need to know more about the patterns of gun violence, and about what steps are most effective in preventing it. We are delighted that President Obama has lifted a longstanding ban on research on gun violence at the Centers for Disease Control and Prevention. Better data will lead to better understanding, which will help craft the best policies.

Finally, we need policies such as the ones discussed above — policies that are effective, that are based on solid evidence and that balance gun-owners’ rights with the community’s interest in reducing gun violence. We are pleased that public discussion of such policies has blossomed in recent weeks (although we mourn the event that set it off). This is the time to protect public health by preventing gun violence.